title: Heroin in brown, black and white: structural factors and medical consequences in the US heroin market.
abstract: BACKGROUND
  Heroin coming into the United States historically comes from three widely dispersed geographical regions: Southwest Asia, Southeast Asia and Mexico. A fourth source of US-bound heroin, from Colombia, originated in the early 1990s. The fact that the four heroin sources produce differing morphologies and qualities of heroin has not been critically examined. In addition, it is not well established how the contemporary competing dynamics of interdiction, or restriction of heroin flows across international boundaries, and neoliberal, e.g., global expansion of free trade, policies are affecting heroin markets. This paper will highlight changes in the US heroin market, including source trends, the political economy of the now dominant source and the resultant effects on the heroin risk environment by US region.
  
  
  METHODS
  Using a structural and historical framework this paper examines two decades of secondary data sources, including government and drug control agency documents, on heroin flows together with published work on the political and economic dynamics in Latin America.
  
  
  RESULTS
  Co-occurring neoliberal economic reforms may have contributed to paradoxical effects of US/Colombian interdiction efforts. Since entering the US market, heroin from Colombia has been distributed at a much higher quality and lower retail price. An increasingly exclusive market has developed with Mexican and Colombian heroin gaining market share and displacing Asian heroin. These trends have had dramatic effects on the risk environment for heroin consumers. An intriguing factor is that different global sources of heroin produce substantially different products. Plausible associations exist between heroin source/form and drug use behaviours and harms. For example, cold water-soluble powdered heroin (sources: Asia, Colombia) may be associated with higher HIV prevalence in the US, while low-solubility "black tar" heroin (BTH; source: Mexico) is historically used in areas with reduced HIV prevalence. BTH is associated with soft tissue infections caused by Clostridium bacteria.
  
  
  CONCLUSIONS
  Source and type of heroin are structural factors in the risk environment of heroin users: source dictates distribution and type predicts practice. How specific types of heroin are used and with what risk is therefore distributed geographically. Continued flux in the heroin market and its effects on the risk environment for drug users deserves further attention.
authors.affiliation: Department of Family and Community Medicine, University of California San Francisco, 500 Parnassus Avenue, MU-3E Box 0900, San Francisco, CA 94143-0900, USA. Ciccaron@fcm.ucsf.edu
authors.forename: Daniel
authors.initials: D
authors.lastname: Ciccarone
mesh_terms: D003015:Clostridium Infections / Q000453:epidemiology / Q000209:etiology; D003132:Commerce; D003415:Crime / Q000706:statistics & numerical data; D004335:Drug and Narcotic Control / Q000706:statistics & numerical data; D015658:HIV Infections / Q000453:epidemiology / Q000635:transmission; D003932:Heroin / Q000737:chemistry / Q000191:economics / Q000266:history / Q000600:supply & distribution*; D006556:Heroin Dependence / Q000191:economics / Q000453:epidemiology* / Q000266:history; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D013287:Illicit Drugs / Q000737:chemistry / Q000191:economics / Q000266:history / Q000600:supply & distribution*; D011057:Politics; D011640:Public Policy; D012306:Risk; D012309:Risk-Taking; D014481:United States / Q000453:epidemiology
chemical_list: D013287:Illicit Drugs; D003932:Heroin